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111 ELECTRICAL PERMIT APPLIICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: ')l j rz4/ . ,1.2 BUILDING AREA: (7,5r47 sq ft <br /> 4 i <br /> PROJECT TYPE: ❑ NEW CONSTRUCTION ElADDITION ❑TENANT IMPROVMENT ekl REMODEL <br /> BUILDING USE: SFR ❑ TOWNHOUSE ❑ DUPLEX El ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK: $ jl[� ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO YES-Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: Complete Re-wire <br /> LOW VOLTAGE WORK? ❑ NO YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): ❑ Data El Intercom ❑Thermostat ❑ Audio ❑ Secure Access ❑ Security System <br /> El Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional <br /> Fire Alarm Permit is required for review of device location and installation approval. <br /> ❑Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO ❑YES--See Below&Pg.2 <br /> By checking this box, I am stating that I have read and understand all of WAC 296-46B-900,selected the specific reason on page 2 <br /> of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not <br /> See Page 2 require Plan Review. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: I NO EYES-See Below&Pg.3 <br /> Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on t(uildings for rent,sale,or lease <br /> without the proper electrical licensing and certification,or exemption.By checking this box, I am stating that I have completed and <br /> See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. <br /> // CONTACT INFORMATION <br /> OWNER NAME: ,71/0 <br /> 1'/1/ 2 TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET% ' �L1F✓;! <br /> CITY 4t4 77 ri/ STATE ZIP . <br /> OWNER PHONE: i! J 5,;'G>�' OWNER EMAIL: 2� z �t `? 1/ <br /> CONTRACTOR NAME: n,C'ife5,47 1; f;—pq/6� <br /> CONTRACTOR ADDRESS: STREET 3'O GL`l'.. - ,/I!L 4/f^ <br /> CITY STATE ZIP l9-2 76 <br /> CONTRACTOR PHONE y,„t' � 2j`.�,')!5/ CONTRACTOR EMAIL: FAt;[/in1(x",^✓4,/e. C [,,t3/41 <br /> CONTRACTOR LIC.#(REQUIRED) W;rkCha / y yo CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O ly5 66 <br /> PRIMARY CONTACT: WI OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ly,2 , 5//y / 7-5' <br /> - i �Nln"� CONTACT EMAIL: ( �' //e)cc <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this <br /> type of work will be completed whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or <br /> local law regulating cogstfuctio or the performance of construction. That I am authorized by the owner of this property to perform the work for which application is made and <br /> comply with the St 16 Cor›,-•'ors L w 2/7 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> rTh <br /> E nc <br /> Owner/Authorized gent Signature Date (Revised 1/11/2019) Page 1-Application <br />